Anatomic study of the middle genicular artery

PURPOSE: To study the anatomy of the middle genicular artery and thus mitigate the risk of vascular injury in knee surgery. METHODS: The course, anatomic relations, and variations of the middle genicular artery in 8 cadavers (4 men and 4 women) were studied. RESULTS: The middle genicular artery originated from the anterolateral surface of the popliteal artery in the popliteal fossa, 3 to 5 cm proximal to the joint line either alone or having a common origin with the lateral genicular artery. Its diameter varied from 2 to 4 mm and it was 3 to 5 cm long. It was accompanied by 2 venae comitantes. This vascular bundle, including the middle genicular artery, ran distally, anterior to the popliteal artery, and posterior to the joint capsule, sandwiched between them. Distally it pierced the posterior joint capsule and became intra-articular. The relation of the middle genicular artery to the popliteal artery altered with the position of the knee joint. This alteration was secondary to the distal gliding of the popliteal artery with knee flexion. The middle geniculate artery formed an angle of 15 to 30 degrees to the popliteal artery when the knee was extended, which became almost a right angle when the knee was flexed past 90 degrees. CONCLUSION: Care must be taken when arthroscopic or open intra-articular surgery is performed in the posterior part of the knee joint using chondrotomes and saws, particularly with limited vision. Sharp dissection and diathermy under direct vision should be safer.     

Proximity of the popliteal artery to the PCL during simulated knee arthroscopy: implications for establishing the posterior trans-septal portal

This study defines the sagittal distance from the posterior cruciate ligament (PCL) to the popliteal artery under simulated arthroscopic conditions. This information is relevant for posterior knee arthroscopy, particularly for the safe establishment of the posterior trans-septal portal. Measurements from the PCL to the popliteal artery were made on sagittal magnetic resonance images obtained in a previous study of 10 fresh-frozen cadaveric knees. The mean sagittal distance from the mid-PCL to the popliteal artery was 29.1 +/- 11 mm (range: 18-55 mm). The mean sagittal distance from the proximal PCL fovea to the popliteal artery was 9.7 +/- 5 mm (range: 3-16 mm). The results of this study provide the arthroscopist working in the posterior compartments of the knee with a more detailed knowledge of the anatomic relationship between the PCL and popliteal artery. This knowledge will help minimize the risk of iatrogenic vascular injury during arthroscopic knee surgery.     

Acute popliteal artery occlusion after arthroscopic posterior cruciate ligament reconstruction

Arthroscopic posterior cruciate ligament reconstruction may carry certain risks of complications, including injury to the neurovascular structures in the popliteal region. Acute occlusion of the popliteal artery, a limb-threatening complication, was reported after total knee arthroplasty. We report a case of acute popliteal artery occlusion after arthroscopic posterior cruciate ligament reconstruction. The possible causes included underlying artherosclerosis, the use of pneumatic tourniquet, surgical manipulation, and arterial spasm. Early diagnosis and prompt surgical treatment are the keys to success in the treatment of this limb-threatening complication. Spontaneous resolution of the thrombus such as is reported in this case is exceptional.     

膝关节镜下膝后侧腔室联合手术入路的探讨

[目的]探讨在关节镜下膝关节后侧腔室联合手术入路的重要性和可操作性。[方法]经过前内侧、前外侧和股骨髁切迹以及后内侧、后外侧和后纵隔内切口联合入路分别入镜、入器械，进行膝关节后侧腔室的探查和手术操作。[结果]216例（239膝）应用联合入路探查和治疗，其中5例膝因关节僵硬操作失败；175例膝用于治疗后侧腔室疾病，膝关节后侧腔室手术视野显著改善，探查和手术操作完善，均达到手术目的。1例膝内侧隐神经不全损伤，没有腘后神经、腓总神经、腘后血管、交叉韧带等重要组织损伤。[结论]膝关节后侧腔室病变较多，是检查和治疗的重要部位，并非“技术盲区”。这种联合手术入路，手术风险低，具备可操作性，可以提高手术效率和质量，可作为膝关节镜下常规手术入路。     

Recanalization of an Occluded Popliteal Artery following Posterior Knee Dislocation

Posterior knee dislocation results in popliteal artery injury in up to one-third of cases. Prompt recognition and treatment of arterial injury is essential for limb salvage. We report a case of complete occlusion of the popliteal artery following posterior knee dislocation treated with saphenous vein bypass without exclusion of the injured arterial segment. Follow-up duplex scanning demonstrated a patent vein graft and a patent ipsilateral popliteal artery. This report suggests that, in some instances, a traumatically occluded popliteal artery may recanalize, and that revascularization with a bypass graft may be the preferred method of repair, particularly in young patients.     

Arthroscopic Treatment of Popliteal Cyst and Visualization of Its Cavity Through the Posterior Portal of the Knee

In regard to arthroscopic treatment of popliteal cysts, we explored the refuted pathology for popliteal cysts proposed by others. Here we introduce an arthroscopic technique using posterior portals to treat a popliteal cyst based on our observation that the opening of the cyst in the joint is a slit-like structure in the posterior wall of the capsule. By disrupting this slit-like structure with our procedure, the popliteal cyst ceased to be palpable and was no longer symptomatic. This technique also provides excellent arthroscopic visualization of the cavity of the popliteal cyst through the knee joint approach. After completion of the resection of the opening, we can easily insert an arthroscope into the cavity of the popliteal cyst from the posteromedial portal through the resected opening. Arthroscopic visualization of the cavity of the cyst showed that the inside wall of the cavity was smooth and had no synovitis. We believe that to disrupt this slit structure is the most pathologically reasonable procedure to treat popliteal cysts surgically.     

Injury to the popliteal artery and its anatomic location in total knee arthroplasty.

Injury to the popliteal artery during total knee arthroplasty (TKA) is a devastating complication. Although infrequent, these injuries can result in the need for further surgery, including revascularization or possibly even amputation. Several mechanisms are capable of producing direct trauma to the popliteal artery, including the use of posterior ret ractors. We investigated the proximity of the popliteal artery to the tibial joint surface during TKA to identify crucial steps in the procedure at which the artery was at highest risk for injury. TKA was performed on cadaveric specimens, and serial intraoperative arteriograms were taken throughout the procedure, demonstrating the potential for arterial injury by the instrumentation. Additionally, 50 transverse magnetic resonance imaging scans of unrelated knees were analyzed for the position of the popliteal artery relative to the midline of the tibial plateau as well as at a level 5 to 10 mm below this, at the site of a typical resection during TKA. All of the arteriograms showed the artery to be a lateral structure at the joint line. Additionally a posterior retractor placed the artery at risk when it was placed in a position lateral to the posterior cruciate ligament or when it was injudiciously inserted more than 1 cm into the soft tissues. Hyperextension of the knee, which might occur during preparation of the patella, produced dramatic tenting of the artery over the posterior joint line. These results demonstrate that the popliteal artery is at significant risk during TKA, particularly if posterior retractors are placed in a position lateral to the midline of the joint. Both hyperflexion and especially hyperextension produced severe deformities and kinking of the artery and would particularly jeopardize an artery with atherosclerosis. Our findings suggest that the popliteal artery may be at least risk during TKA if posterior retractors are placed medial to the midline of the tibial plateau and if care is taken to avoid extremes of both flexion and extension.     

全膝关节置换术中腘血管损伤的危险三角区域

 目的 探讨全膝关节置换术中腘血管损伤的危险区域。方法 回顾性分析2012年5至12月拍摄的1 291例膝关节MRI片,男564例,女727例;年龄16～87岁,中位年龄37岁;右侧565例,左侧726例。在横断位MRI片上测量膝关节髁上连线水平腘动脉与股骨外侧髁的最短距离（PA-LFC）、关节线水平腘动脉与后关节囊的距离（PA-PC）、关节线以下10 mm水平腘动脉与胫骨后方皮质的距离（PA-PTC）;在矢状位MRI片上测量腘动脉与胫骨后方皮质的最短距离（PA-PTCs）及腘动脉与后十字韧带的内外侧关系。取6具新鲜冰冻尸体膝关节标本,明确腘动脉的位置,测量其与膝关节囊及腘肌的距离。结果 1 291例膝关节MRI中出现腘动脉高位分叉变异17例（1.32％,17/1 291）。PA-LFC、PA-PC、PA-PTC及PA-PTCs分别为（4.89±1.80）mm、（4.05±1.43） mm、（3.61±1.39）mm及（3.58±1.04）mm。膝关节积液增加PA-LFC和PA-PC的数值,但不增加PA-PTC和PA-PTCs的数值。腘动脉总是位于血管神经束最前方。在关节线水平,腘动脉均位于后十字韧带内缘的外侧。尸体解剖显示膝关节线距腘肌上缘（1.13±0.23） cm,该段腘动脉及其分支构成一个三角形区域,紧贴关节囊和胫骨皮质,三角形后方为腘动脉主干、膝外下动脉、膝正中动脉等密集分布的区域。结论 腘动脉损伤危险三角形区域后方存在重要的缺乏足够软组织保护的血管,包括腘动脉、膝外下动脉、膝正中动脉及一些无名小动脉,在全膝关节置换术中应注意保护。     

关节镜下后内入路治疗腘窝囊肿的疗效分析

目的探讨关节镜下后内入路治疗腘窝囊肿的疗效分析,并将其与传统开放性手术治疗方式作比较。方法回顾性研究自2014年1月至2019年1月于我院收治的68例腘窝囊肿患者,男30例,女38例;年龄33-61岁,平均(43.01±5.39)岁。其中关节镜下后内入路手术治疗组32例,传统开放性手术治疗组36例。统计两组患者的手术时间、手术切口长度、住院时间、复发情况,并采用Rauschning和Lindgren腘窝囊肿分级评分标准、Lysholm膝关节评分、视觉模拟评分(visual analogue scale,VAS)判定患者的治疗效果。结果所有患者术后均获5-12个月随访,平均(8.46±2.40)个月。术后关节症状明显缓解,关节功能明显改善。关节镜手术组无囊肿复发,开放手术组有2例在手术后3-6个月复发,经关节镜下手术后症状消失。关节镜治疗组患者在手术切口长度、住院时间、复发情况、膝关节VAS、Lysholm膝关节评分、Rauschning和Lindgren腘窝囊肿分级评分标准均明显优于开放手术组,差异有统计学意义(P<0.05)。结论关节镜下后内入路治疗腘窝囊肿是一种安全、有效的治疗方法。     

Pseudoaneurysm complicating knee arthroscopy. A case report

Pseudoaneurysm formation is a rare complication after knee arthroscopy. Most pseudoaneurysms complicating knee arthroscopy develop on the popliteal and geniculate arteries. We report a case of a pseudoaneurysm developed on an arterial branch to the medial gastrocnemius muscle, as a complication of an arthroscopic meniscectomy in a 66-year-old patient. The patient was treated successfully by resection of the pseudoaneurysm and ligation of the injured artery.     

Flexion of the knee increases the distance between the popliteal artery and the proximal tibia: MRI measurements in 15 volunteers

We determined which angle of flexion best prevents popliteal artery injury during knee surgery. We took MRIs of the knee in the lateral position with the knee in 0°, 45°, 90°, and 120° of flexion in 15 volunteers. The shortest distance between the posterior cortex of the tibia and the popliteal artery was measured at various levels from the knee joint to 60 mm distally. At the level of the joint and 15 mm distally, the distance between the tibia and artery increased with increasing knee flexion. More distally, no significant difference was noted with increasing flexion. Flexion of the knee may minimize injury to the popliteal artery in procedures between the level of the joint and 15 mm distal to the joint.     

Flexion of the knee increases the distance between the popliteal artery and the proximal tibia: MRI measurements in 15 volunteers

We determined which angle of flexion best prevents popliteal artery injury during knee surgery. We took MRIs of the knee in the lateral position with the knee in 0 degrees, 45 degrees, 90 degrees, and 120 degrees of flexion in 15 volunteers. The shortest distance between the posterior cortex of the tibia and the popliteal artery was measured at various levels from the knee joint to 60 mm distally. At the level of the joint and 15 mm distally, the distance between the tibia and artery increased with increasing knee flexion. More distally, no significant difference was noted with increasing flexion. Flexion of the knee may minimize injury to the popliteal artery in procedures between the level of the joint and 15 mm distal to the joint.     

Flexion of the knee increases the distance between the popliteal artery and the proximal tibia: MRI measurements in 15 volunteers

We determined which angle of flexion best prevents popliteal artery injury during knee surgery. We took MRIs of the knee in the lateral position with the knee in 0°, 45°, 90°, and 120° of flexion in 15 volunteers. The shortest distance between the posterior cortex of the tibia and the popliteal artery was measured at various levels from the knee joint to 60 mm distally. At the level of the joint and 15 mm distally, the distance between the tibia and artery increased with increasing knee flexion. More distally, no significant difference was noted with increasing flexion.

Flexion of the knee may minimize injury to the popliteal artery in procedures between the level of the joint and 15 mm distal to the joint.     

Variations and anomalies of the popliteal and tibial arteries

A review of the anatomic characteristics of the popliteal artery and its tibial branches was performed in 147 patients. The anterior tibial artery arose 6 to 8 cm below the knee joint in 91 percent of the limbs. The posterior tibioperoneal trunk was 2 to 5 cm in length in 87 percent of the patients. In 5 patients (3 percent), the posterior tibial artery originated directly from the popliteal artery proximal to the anterior tibial origin. It was located either at the knee joint or within 5 cm of it. In 75 percent, the anomalies were bilateral.     

Popliteal Artery Pseudoaneurysm After Arthroscopic Cystectomy of a Popliteal Cyst

A case of popliteal artery aneurysm after arthroscopic cystectomy of a popliteal cyst is an uncommon complication, and no case has been reported. We present a case of pseudoaneurysm of the popliteal artery after arthroscopic cystectomy of a popliteal cyst 2 months after surgery. Open excision of the pseudoaneurysm and popliteal artery pin-point repair were done. At 30 months' follow-up, both the tibialis posterior and dorsalis pedis pulsations were felt equally on both sides with normal sensations over the limb. Retrospectively reviewing the case, we found that the relation of the popliteal artery and popliteal cyst on preoperative magnetic resonance images can predict the complication of pseudoaneurysm of the popliteal artery. It is better not to shave the lateral aspect of the cyst while performing arthroscopic cystectomy when magnetic resonance images show that the popliteal artery is close to the cyst.     

Proximity of the posterior cruciate ligament insertion to the popliteal artery as a function of the knee flexion angle: Implications for posterior cruciate ligament reconstruction

Purpose: The purpose of this study was to determine if an optimal knee flexion angle existed that would minimize the risk of neurovascular injury from the passage of transtibial hardware during posterior cruciate ligament (PCL) reconstruction. Type of Study: Cadaveric. Materials and Methods: Fourteen fresh-frozen cadaveric knees were mounted in a Plexiglas apparatus that could be set at 5 different knee flexion angles (0°, 45°, 60°, 90°, and 100°) while joint distention was maintained. Each knee underwent magnetic resonance imaging in the axial and sagittal planes at each of the 5 flexion angles to determine the distance between the PCL tibial insertion and popliteal artery. Results: The mean distance, over all 5 flexion angles, between the PCL insertion and the popliteal artery in the axial plane was 7.6 mm, whereas the mean distance in the sagittal plane was 7.2 mm. There was a significant increase in distance with progressive flexion in both planes. Maximum mean distances were noted at 100° of flexion in both the axial (9.9 mm) and sagittal (9.3 mm) planes. An artificial line mimicking the path of a transtibial drill passed through the popliteal artery in 10 of 10 cases at the 0°, 45°, 60°, and 90° angles, and in 6 of 10 cases at the 100° angle. Conclusions: The results of this study suggest that increasing knee flexion reduces, but does not completely eliminate, the risk of arterial injury during arthroscopic PCL reconstruction.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 8 (November-December), 2000: pp 796–804     

关节镜前后路联合手术囊外切除腘窝囊肿

目的：探讨应用关节镜技术前后路联合手术囊外切除腘窝囊肿的方法及临床疗效.方法：自2010年1月至2012年12月收治腘窝囊肿20例,其中男14例,女6例;年龄45～65岁,平均49.5岁;左膝12例,右膝8例.发现腘窝肿块4～18个月,平均12个月,囊肿大小体表纵径3～7 cm,平均4.5 cm.主要临床表现为腘窝部肿块,膝关节肿痛,并伴有不同程度的功能障碍.由MRI确诊为腘窝囊肿,并均与关节腔相通.先后路行关节镜下囊肿囊壁剥除术,后前路关节镜下处理关节内疾患.术前Rauschning和Lindgren腘窝囊肿分级：Ⅰ级2例,Ⅱ级6例,Ⅲ级12例.通过比较手术前后Rauschning和Lindgren腘窝囊肿分级情况对术后临床疗效进行评定.结果：20例术后均未出现并发症,切口均Ⅰ期愈合.所有患者获随访,时间8 ～24个月,平均16个月,膝关节疼痛症状明显好转,囊肿无复发.术后8个月按Rauschning和Lindgren腘窝囊肿分级法分级：0级14例,Ⅰ级6例,术后腘窝囊肿分级情况明显改善.结论：应用关节镜技术前后路联合手术治疗腘窝囊肿临床疗效满意,囊肿囊壁剥除,同时处理关节腔内疾患,可降低囊肿的复发率.     

Proximity of the posterior cruciate ligament insertion to the popliteal artery as a function of the knee flexion angle

Purpose: The purpose of this study was to determine if an optimal knee flexion angle existed that would minimize the risk of neurovascular injury from the passage of transtibial hardware during posterior cruciate ligament (PCL) reconstruction. Type of Study: Cadaveric. Materials and Methods: Fourteen fresh-frozen cadaveric knees were mounted in a Plexiglas apparatus that could be set at 5 different knee flexion angles (0°, 45°, 60°, 90°, and 100°) while joint distention was maintained. Each knee underwent magnetic resonance imaging in the axial and sagittal planes at each of the 5 flexion angles to determine the distance between the PCL tibial insertion and popliteal artery. Results: The mean distance, over all 5 flexion angles, between the PCL insertion and the popliteal artery in the axial plane was 7.6 mm, whereas the mean distance in the sagittal plane was 7.2 mm. There was a significant increase in distance with progressive flexion in both planes. Maximum mean distances were noted at 100° of flexion in both the axial (9.9 mm) and sagittal (9.3 mm) planes. An artificial line mimicking the path of a transtibial drill passed through the popliteal artery in 10 of 10 cases at the 0°, 45°, 60°, and 90° angles, and in 6 of 10 cases at the 100° angle. Conclusions: The results of this study suggest that increasing knee flexion reduces, but does not completely eliminate, the risk of arterial injury during arthroscopic PCL reconstruction.     

Popliteal A-V Fistula with Pseudo-aneurysm: A Complication Following Total Knee Arthroplasty

Arthroscopy and total knee replacement (TKR) are the two orthopedic procedures in which instruments are routinely placed near the posterior capsule of the knee. A review of the literature demonstrated that the four commonest reported problems following TKR are thrombosis, arterial transection, A-V fistula, and aneurysm formation. Reports on popliteal artery injury with severe patient morbidity following arthroscopy and TKR have been described in the literature. Despite the uncommon occurrence of these injuries, the outcome can be devastating, leading to further surgery, including vascular repair or possibly even amputation of the affected limb. We present a rare case of popliteal A-V fistula following TKR and discuss the probable etiology and the management.     

Surgical approach to the treatment of popliteal aneurysm

Seventeen popliteal artery aneurysms were repaired at the Santa Barbara Cottage Hospital from 1975 to 1987. Fourteen patients were involved, with three having bilateral lesions. All but one were men with an average age of 67 years. Four of the aneurysms (three patients) presented with asymptomatic masses while the others were associated with arterial or venous obstructive symptoms. The aneurysms were repaired and there was no mortality. One patient developed a transient foot-drop. All patients with symptoms caused by their aneurysm were improved or became asymptomatic, postoperatively. We are impressed that the posterior approach to an uncomplicated popliteal artery aneurysm has several advantages over the bypass technique. The distal anastomosis can frequently be kept proximal to the knee joint, and since exposure of the aneurysm is excellent, aneurysmectomy is often possible thus eliminating pressure symptoms as well as the possibility of late rupture.